Everyone has an opinion about NFL draft prospects, but the ones that count the most come from team doctors and athletic trainers who advise behind the scenes about joint damage and concussion history

The Rams will be one of the busiest teams this week, with a dozen picks to use in the NFL draft, including Nos. 2 and 13. So how did the team’s top decision-makers, general manager Les Snead and coach Jeff Fisher, start their week? By blocking off Monday night for a meeting with their medical staff.

This late in the process, medical checks (and re-checks) are among the few things that can truly cause a player to rise or fall on draft boards. This part of the pre-draft appraisal takes place entirely behind closed doors, so it doesn’t create as much buzz as pro days or 40 times. But all 32 teams will hold meetings like the Rams did last night, using team doctors and athletic trainers to help answer the vital draft-weekend question: Is a player safe to draft?

Safe means two things: 1) Physically safe to play the game, a doctor’s first responsibility, and 2) Worth the risk of investing a draft pick, a decision that team brass makes with the help of input from the medical staff.

Each player considered during the three-day draft will have a pair of medical grades, one for orthopedic health and another for overall health. The grades follow a simple rubric—for instance, the Rams use A through F, while the Chiefs use 1 through 5—so the information is simple and accessible to team executives. These evaluations are but one piece of the puzzle, but they’re an important one because they can help predict how often and how long a player will be able to use his talents on the field.

The MMQB spoke to three NFL team physicians—Matt Matava (St. Louis), Anthony Casolaro (Washington) and Michael Monaco (Kansas City)—about their role in advising for the draft. Anything from wear and tear on a player’s joints to concussion history can affect a team’s willingness to invest time and money.

“Concussion history does make a big difference,” says Monaco. “If it is significant—not just the number, it may be the severity—it will have an impact on their score, and we’ll make sure team administrators are aware of it as they make decisions. There’s always the potential it could disqualify a player, but we have been fortunate that it has not. But clearly, it has a big impact on how we assess players and assign risk.”

Grading the Prospects

Players are often jarred at the NFL combine when they walk into a room full of doctors, hop up on an exam table and are promptly announced by their name and corresponding ailments: Loose right shoulder, reconstructed left ACL, and so on. For team medical staffs, this is how they begin building medical records on the more than 300 college stars invited to the combine.

Each team has a chance to do a physical orthopedic exam on each player—to feel firsthand the stability of a troubled joint or ask questions about his rehab—in addition to reading his MRI and X-Ray results. They’ll usually do so for the top prospects or a list of players the team has special interest in. Players also undergo one general medical exam, and the results are shared with all 32 teams, including blood count, urinalysis, sickle-cell screening, EKGs and stress tests. Following the NBA’s lead, the NFL began performing an echocardiogram on every player (the test that picked up defensive tackle Star Lotulelei’s temporary heart condition in 2013) a few years ago.

The challenge is for doctors to fit each unique medical record into a grading rubric. Matava, an orthopedic surgeon, says his orthopedic grades usually follow a bell curve. Only about 10% of players, usually punters and kickers, receive As. He mostly awards Bs and Cs, based on the number of operations a player has had and signs of wear and tear. At the bottom end of the spectrum is a handful of ‘D’ players, who will have their careers limited by orthopedic issues like multiple joint reconstructions and signs of arthritis.

NFL team doctors are worried that if players are aware their concussion history can impact potential draft status, they’ll be more likely to mask symptoms in college.

The grades for overall health follow a different pattern, because survival of the fittest plays a role in selecting the group of elite athletes who are on the verge of the NFL. About 25% receive an A or a 1. If a player has a chronic condition, like diabetes or asthma, but has it under control, he may receive a B. Any player entering the NFL has to first be cleared to play football, but questions of safety don’t always have yes or no answers. For instance, if a player has sickle-cell trait, which makes him susceptible to organ damage at high altitude, he may receive a lower grade from the Broncos than from other teams.

Factoring in concussion history is also an inexact science. The total number and recovery time for each head injury are the two most important considerations, but Casolaro says there is no simple formula to calculate a grade. Making it more difficult, different colleges may report and manage head injuries differently, and there are no such records available to teams from a player’s high school or youth football experience.

“If a player missed a month with a concussion and had two before that, that would change the way I would advise the team to look at him,” Casolaro says. “He’s been cleared, all things are back to normal, but it does affect how a player might be viewed. That’s just the truth. But we have to be careful how that gets out.”

Casolaro is worried that if players are aware their concussion history can impact potential draft status, they’ll be more likely to mask symptoms in college—one of the many gray areas in the push toward a safer game. About five years ago, the NFL also started inviting two collegiate medical staffs to the combine per year, to emphasize the importance of keeping thorough and detailed records on each player.

“It probably helps the college to have players drafted high and get notoriety,” Casolaro says. “I’m not saying they are less likely to be straightforward, but I worry some of the info we get isn’t as comprehensive as it could be. When they come, they understand there is a larger goal here.”

Medical grades are not set in stone after the combine. Players can be examined again during pre-draft visits to team facilities, and about 50 players are tagged for a medical re-check in Indianapolis that takes place two weeks before the draft. For players coming off injury, teams need to know how they are progressing, if they’ll be ready to compete in camp—and, first and foremost, are they draftable?

A Doctor’s Influence

When Matava met with the GM and coach on Monday night at Rams Park, he was prepared to field questions from Snead and Fisher about the team’s top 100 prospects. There’s a lot of talk this time of year about players coming off the board because of medical reasons, but that’s not a call the doctor makes.

“[Snead and Fisher] have the ultimate say, and if the player’s football ability is so stellar and outstanding, they may want to take a risk from a medical standpoint on drafting a guy,” Matava says. “That’s their call. Some physicians say if you flunk a guy, you affect his ability to make a living; I’m not sure of that. But I never will tell a GM or coach a player ‘failed’ the exam. It’s all relative.”

The medical grades may carry different value for different positions or players. A potential first-round draft pick, for instance, may be with the team for five years or longer, while a projected late-rounder or an undrafted free agent (the same grades apply to free agents) may only have a two or three-year career. The general manager and coach usually ask for more information about players in the C range—those who may be on the cusp of a significant orthopedic issue, such as arthritis, or someone with an extensive concussion history.

“It is a judgment call,” Casolaro says. “We’ve had kids graded as a 3+ from concussions (equivalent to a C-), and they went through the next three, four years without any. Maybe some changed their playing style. It is a bit of an unknown. You’re looking at a potential influence on health status; it is not a definite. You’re looking at relative risk.”

During the draft, team physicians are either in the war room or on call. Their work has been completed by this point, but team brass might turn to them for final reassurance before drafting a player with a medical question mark, or to break a tie between two prospects.

The draft comes down to an exercise in risk management, and in a physical league, medical risk matters. Football ability gets a player to the NFL, but they won’t stick around for long if they aren’t healthy.